Holistic approach helps plan provide care for members with special needs

Case management, social work go hand-in-hand

Since Horizon NJ Health plan started its Care Coordination Unit (CCU), a comprehensive, holistic program for Medicaid beneficiaries with special needs in 2000, costs of care for special-needs members have dropped in many cases.

Special-needs members typically utilize three times the resources the average member uses, says Karen Szerlik, RN, CMCN, team leader of the CCU.

"The special-needs patients in the program have very complex medical needs and can be financially draining on a plan. Our goal is to provide quality care for these members and to manage them in order to keep them out of the hospital," she adds.

The CCU case managers work with populations of all ages with mental and physical disabilities and complex medical conditions. Members in the program range in age from infants to the elderly, and many have multiple comorbid conditions, including mental health problems.

Some of the members have specific disabling conditions such as quadriplegia, paraplegia, cerebral palsy, spina bifida, Down syndrome, and autism. Others have complex chronic conditions such as HIV/AIDS, sickle cell disease, and end-stage renal disease. Others may be waiting on an organ transplant or undergoing cancer treatment.

The CCU case managers take a holistic approach to coordinating care and often work with the plan’s social work case managers to help with members’ nonmedical needs, including housing, food, transportation, and utilities.

"In order to promote good medical outcomes, we address the member in a holistic way, including providing support to the caregivers of an adult or the parent of a child. If psychosocial support is not provided for patients with special needs and their caregivers, the outcome is likely to be very poor," Szerlik adds.

The CCU case managers look at the needs of the members they work with and seek to meet them, whatever those needs are. For instance, if a member is wheelchairbound and needs transportation to the physician or clinic, the case managers authorize that the member receive transportation assistance.

"It benefits no one when our team works so diligently on behalf of a member if that member is not able to get to the doctor to get medical care. This holistic approach helps remove all barriers to care and helps the members and their caregivers enjoy a high quality of life, " Szerlik points out.

The CCU case managers collaborate with the health plan’s social case managers to provide the members with linkages to community agencies that can help with their care, adds Cathy Kelly, RN, BA, CMCN, manager of clinical operations.

For instance, if a member has cerebral palsy, the case managers help them get access to a cerebral palsy clinic and also help the caregiver get involved with a support group.

"With chronic diseases such as cystic fibrosis, cerebral palsy, muscular dystrophy, and sickle cell disease, care can be enhanced with social support. Because many of our members have been in other Medicaid programs that don’t offer or even have this kind of social support, they do not know how to access community resources," she adds.

The CCU case managers coordinate with the social case managers and durable medical equipment providers to assure that the members have everything they need after discharge.

For instance, when a sick baby is in the hospital, the case manager gets the social case manager involved to make sure that resources are in place to meet all of the family’s needs.

"While the child is still in the hospital, we make sure that the family has housing and anything else necessary to care for the child’s physical needs. As every nurse knows, discharge planning begins at admission, and we try to connect the family with all the community resources they will need," Kelly says.

In one case, the social case manager intervened when a baby on a ventilator was being discharged to a home where the electrical services were inadequate to keep the ventilator operating.

The case managers make sure the durable medical equipment company does a home evaluation before any equipment is provided.

"If you provide a $20,000 electric wheelchair to somebody who lives on the 16th floor of a building with no elevator, you’re doing them a disservice. We check the home out before the member receives the service," Szerlik says.

On occasion, the CCU case managers will visit their clients in the home if they feel a personal visit is necessary to review the situation and the members’ needs.

"If we feel that our eyes in the community or our community contacts and linkages are missing something that could impact the health and welfare of the member or we have a concern that something isn’t what it might appear to be on the surface, we send our nurse case managers or the social case managers out to the house so that we can provide the best services possible for each case and each member’s needs," Szerlik says.

For instance, one patient was having problems with the bedrails breaking constantly when she was turned over for wound management. The case manager talked to both the home health nurse and the member’s husband and discussed the problem with the equipment company.

When Szerlik visited the home, the case manager discovered that the bed was so small that the woman had very little room in which to maneuver. She only had five inches in which to turn around. Szerlik arranged for a larger bed and solved the problem.

"Our nurses come from an acute hospital background and have a lot of clinical experience. They are able to pick up on cues that indicate that something is wrong and to take steps to fix it," she says.

Every member who is stratified to Level 2 or Level 3 receives both medical case management and social case management.

"Mental health is a very big issue, whether it’s a need for counseling for behavioral issues or difficulty in coping or helping relive the stress a caregiver experiences when taking care of a special needs patient," Szerlik reports.

The case managers are able to give social support and to help families tap into resources that will provide respite care.

It means a lot to family members to know that they have someone to talk with when they have problems or just need a shoulder to cry on, Kelly says.

"Some families have two or three special needs children. It’s hard to imagine the demands put on these caregivers," she adds.

The health plan coordinates care for all members, but the special-needs members often need a lot of coordination, Szerlik says.

For instance, some members with complex medical needs may be going to as many as five different hospitals for care. The case managers set them up for care at a tertiary care center with various specialists so they can receive care in one place.

In the case of newborns with special needs, the case managers help the mother understand what their infants require, help them coordinate visits to specialists, and assist them in connecting to services in the community that they need.

When a member joins Horizon NY Health, the outreach staff begin an aggressive program to get in touch with the member so they can conduct a screening to see which programs would best benefit him or her.

"We make numerous attempts to get to the member by telephone, send out letters if there is no phone number available, and work with the primary care physician to locate the member," Kelly says.

The prescreening questionnaire contains triggers that indicate if the member needs a more extensive risk assessment to determine if he or she qualifies for the special-needs program.

Primary care physicians, internal staff, and self-referral also make referrals to the program from members.

The case managers receive the referrals and conduct a risk assessment to determine if the member has complex needs. The risk assessment stratifies members into three categories, each with different levels of contact.

Members on Level 1 receive at least one outreach attempt annually. Case managers are in touch with Level 2 members on a monthly basis and those on Level 3 twice a month.

During the initial contact, they begin educating the member on the services that Horizon NJ Health will provide.

"Most of the members are accustomed to straight Medicaid fee-for-service. We discuss and explain the services we provide and help them navigate through the system," Kelly says.

The health plan also sends the members a formal letter introducing them to their case manager with a telephone number they can call if they have questions or problems.

Any case that is referred to the Care Coordination Unit stays open as long as the member is in the plan. Members’ levels can change, depending on their needs at the time, and the type of support they need may change over time.

"It’s one thing to understand what a little baby needs. As a person with cerebral palsy or muscular dystrophy grows older, the caregivers also need someone to talk to about the evolving needs," Kelly adds.

The staff at Horizon NJ Health have biweekly multidisciplinary meetings to discuss the needs of the members. Staff attending include the medical director, pharmacist, social case manager, regulatory affairs, and legal services if needed.

The case managers bring up specific cases with unresolved issues, and the team collaborates on how to resolve the problems.

"In a holistic approach, the case manager needs to address counseling support. For instance, if we have a member in a pain management program, it’s critical for them to develop a coping mechanism," she says.

The case managers coordinate dental care for special-needs patients through Horizon Dental’s special-needs program for dental services.

Many of the children are wheelchairbound and have behavioral issues that make it difficult for them to receive dental care from a dentist who is not skilled in working with special-needs patients.

"These children can’t express that they’re in pain, but they may exhibit behavior outbreaks. In any case, they still need routine dental care. Our nurse case managers work with Horizon Dental to make sure they get special needs dentistry," she says.